HELENA – A last-minute change to a 2019 bill put an end date on Montana’s Medicaid expansion program, setting the stage for what is anticipated to be the most significant health care debate of the 2025 Montana Legislature.

In recent interviews, legislative leaders predicted a vigorous debate over keeping the Medicaid expansion program, which pays the medical bills of more than 75,000 low-income Montanans at an annual cost of about $1 billion to the federal and state governments. They also expect the topic to seep into other health policy decisions, such as the approval of new spending on Montana’s behavioral health system and regulation of hospital tax-exempt status.

“It all kind of links together,” said state Sen. Dennis Lenz, a Billings Republican and chair of the Senate Public Health, Welfare, and Safety Committee.

Legislators from both parties also expect lawmakers from the GOP majority to continue to pursue abortion restrictions, despite a November statewide vote making abortion a right under the Montana Constitution.

The Medicaid expansion debate, however, looms largest among the health care topics.

“This is definitely the elephant in the room, so to speak,” said Senate Minority Leader Pat Flowers, a Belgrade Democrat.

Montana expanded Medicaid, initially for four years, in 2015, through a coalition of minority Democrats, some moderate Republicans, and a Democratic governor. A similar coalition renewed the program in 2019, but at the last moment, Senate Republicans tacked on an end date of June 30, 2025. That put the matter in the lap of this year’s legislature.

Republicans still hold strong majorities in the state House and Senate, whose leaders voiced concerns about the expansion program.

This time around, the governor — Greg Gianforte — is a Republican. Last year, the Gianforte administration completed a postpandemic eligibility reassessment that cut the number of expansion enrollees from a high of 125,000 people in April and May 2023 to approximately 76,600 people as of October, the most recent data available.

Gianforte has included funding for Medicaid expansion in his proposed budget, which must be approved by the legislature to take effect. His office said he wants “strong work requirements for able-bodied adults without dependents” to take part in the program. Spokesperson Kaitlin Price said the governor “has been clear that the safety net of Medicaid should be there for those who truly need it, but that it will collapse if all are allowed to climb on it.”

GOP legislative leaders clearly are skeptical of the program, saying it won’t continue without some “sideboards,” or additional requirements of enrollees and providers.

Whether any expansion bill passes “will depend on the people pushing it,” said Senate President Matt Regier, a Kalispell Republican who opposes expansion. “If there is no give-and-take, it could be an interesting vote.”

Flowers said he knows getting Medicaid expansion through the Senate will be tough. Republicans hold a 32-18 majority, and the GOP caucus leans conservative.

“There are a lot of my colleagues on the Republican side that are ideologically opposed, and I think you’re going to see that in their consistent voting against reauthorizing,” Flowers said.

Medicaid, funded by both the state and federal governments, provides health coverage for certain groups of low-income people. Expansion extended Medicaid coverage to nondisabled adults ages 19 to 64 with incomes up to 138% of the federal poverty level — about $20,800 a year for an individual in 2024.

The 2010 federal Affordable Care Act opened Medicaid to this new group of adults, starting in 2014. But a 2012 U.S. Supreme Court ruling said states could choose whether to adopt the change, and 40 have done so.

Republican state Rep. Ed Buttrey said he would sponsor a bill to reauthorize Medicaid expansion without an expiration date, but many GOP lawmakers remain unconvinced that expansion is needed, viewing it as a costly, unnecessary welfare program.

“I understand there are some pros to Medicaid expansion, but, as a conservative, I do have issues with — I guess I can’t get around it — socialized medicine,” said House Speaker Brandon Ler (R-Savage).

In September, representatives from a pair of conservative-funded think tanks made a case for ending Medicaid expansion, saying its enrollment and costs are bloated. The consulting firm Manatt, on the other hand, said more people have access to critical treatment because of Medicaid expansion.

At the least, it appears many Republicans want to require participants to work, pay premiums, or meet other conditions, if the program is to continue.

Premiums and work requirements are in Montana’s law right now. The Biden administration, though, nixed both, so they haven’t been in effect. Montana Republicans expect the incoming Trump administration to be more open to such provisions.

Democrats say Medicaid expansion has succeeded on many fronts: covering thousands of low-income workers, helping keep rural health care providers and hospitals afloat, and bringing hundreds of millions of federal dollars into Montana’s economy. The state pays 10% of the program’s costs, which totaled about $962.4 million in fiscal year 2024. The federal government picked up $870 million of that tab.

“With all that, it’s just stunning to me that there could be opposition,” Flowers said. “There is just no reason for us, collectively as a state, not to support this.”

Democrats will have their own expansion bill, brought by Rep. Mary Caferro of Helena. She said the bill would remove the work requirements and premiums, shine more light on the contracting activities of the state health department, and reopen some public assistance offices that have been closed. It also would make expansion permanent.

“We’re 10 years into this program,” said Rep. SJ Howell of Missoula, the Democratic vice chair of the House Human Services Committee, which debates health policy legislation. “I think that continuing a cycle of uncertainty for patients and providers doesn’t make sense.”

Legislators also see the expansion debate tying into other health care discussions.

Regier and Lenz said Montana’s nonprofit hospitals — strong supporters of expansion — have benefited greatly from the program and may need to give something back in return. One possibility: more government oversight of the “community benefits” that hospitals must provide to receive tax-exempt status.

They also noted that Montanans pay a fee for hospital stays to support the Medicaid program and that a fee on hospital outpatient revenue helps pay the costs of Medicaid expansion. Those fees and the resulting money raised for hospitals may merit review, they said.

Meanwhile, backers said Medicaid expansion underpins one of the governor’s major policy priorities, to improve the state’s behavioral health system. Gianforte has proposed spending up to $100 million over the next two years on 10 recommendations made by an advisory commission that reviewed the system for the past 18 months.

If Medicaid expansion ends, many adults would lose access to the mental health and addiction treatment system that Gianforte wants to improve, advocates said, while treatment providers would lose a significant source of revenue.

Money for the behavioral health changes would come, in part, from a $300 million fund created by the 2023 legislature. Lawmakers plan to scrutinize Gianforte’s proposals during the budgeting process. Howell said Democrats want to look at whether the changes would use enough of the $300 million fund quickly enough and on the most pressing needs.

Meanwhile, Republicans said they’ll likely introduce bills on abortion — even though Montanans approved Constitutional Initiative 128 by a 58-42 margin in November. CI-128 said the right to an abortion cannot be “denied or burdened” except by a “compelling government interest achieved by the least restrictive means.”

“It’s not going to slow us down in our pro-life positions,” Ler said of CI-128.

At a minimum, GOP leaders said, some of CI-128’s terms should be defined.

“With a very poorly written ballot initiative like that, we need to say, ‘What does that abortion industry look like under CI-128 and what’s our role as a state?’” Regier said.

But state Sen. Cora Neumann, a Bozeman Democrat on the Senate Public Health, Welfare, and Safety Committee, said the CI-128 vote provided a strong mandate for the right of privacy.

Enacting restrictions would lead to “that slippery slope of what’s next, if we allow legislators to rule on what’s happening in the doctor’s office,” she said. “What kind of can of worms could be opened to other invasions of privacy?”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.